Author: Dr. Lloyd P. Nattkemper D.D.S. AMED Charter Member
Article published in the journal AMED Vision News | vol 4 issue 3
Periodontists using microscopes for their surgical procedures face numerous challenges. Among these:
Even when these problems are overcome, others can be formidable. Most entail figuring out patient/scope positions that allow direct vision, or how to incorporate your assistant to help retract and suction, or for them to hold a mirror. In my experience, unless a periodontist is particularly gifted and able to “think outside the box”, they would be wise to take a course in use of the operating microscope — one which addresses ergonomics, effciency, considerations for the staff and opertory set-up, and most important, use of the ‘scope in each area of the mouth. With instruction and subsequent practice, instead of feeling like a dope or generally lame, they will start feeling competent and even, yes, cool.
I am talking with my patient about what he is observing on the overhead screen. We have found that watching what we are doing is a terrific way of reducing “fear of the unknown” during surgery and getting patients excited about their periodontal treatment
We often supplement the microscope light with a standard opertory light for most flap procedures to improve the assistant’s visualization of the operating field
Here I would like to address use of the ‘scope for periodontists in one of the more problematic regions of the mouth: the palate. What I will offer here is based partly on what I have learned from mentors — including Dennis Shalelec, Peter Nordland, Rick Schmidt, Martin Boudro, Glen Van As and Wayne Remington — and mostly from twelve years’ practice using a microscope. What I will offer here is not “how you should do it”. It’s how I do it, and my hope is that if you are frustrated with palatal surgery using the microscope, what I offer here might serve to help you past frustrations and along the road towards cool.
Because of the necessity for the operator to use both hands in manipulation of surgical instruments during graft harvest procedures, I have found it necessary to use direct vision. I will comment off the bat that a highly skilled assistant who is comfortable working totally from a video screen can suction and hold a mirror (usually a large, oblong mirror such as is used for intraoral photography) for you simultaneously — allowing indirect vision and simplified ergonomics.
Large monitor on movable arm allows the assistant excellent visualization of field
However, my assistants are not comfortable doing this. So I have learned to adjust patient and microscope to allow direct vision. This requires:
I have found that harvest of grafts from the right palate is more problematic than the left when using the ‘scope, in that certain individuals have long or lingually inclined maxillary incisors which, even with quite a severe tilt to the ‘scope, block direct vision. As such, there are certain procedures in which you must default to unaided vision or use of loupes.
initial incision completed with 15C blade
probe used to assess length of incision
flap created with 6915 blade
The technique I use for graft harvest involves a horizontal incision placed 2-3mm palatal from the teeth, with short (3-4mm) vertical incisions at either end. I try to avoid going distal to the first molar or mesial to the canine. A 6915 blade is used to gently dissect a flap, about 1 to 1.5mm thick, extending 5 to 6mm from the initial incision palatally. The same blade is then used to dissect the connective tissue graft, either away from the palatal bone (if a thin palate) or away from the periosteum. A fresh blade is used to carefully free the base of the graft away from the underlying and overlying connective tissue. The graft is stored in saline while the palate is sutured.
|CT exposed, beginning secondary incision||completing graft harvest; note 1mm endo suction tip||suturing donor area|
A continuous suture is placed, beginning just beyond the incision, with a loop about every 1.5-2mm. This technique allows primary closure of the site and I have not found it necessary, at least in the 12 years I have used this technique, to place a palatal stent. Currently I use a 6/0 or 7/0 polypropylene suture. This material is quite strong in spite of its tiny dimension and elicits virtually no infammatory reaction. Although patients frequently will request resorbable suture, I have found that these often lose strength before tissues have attained suffcient integrity and can lead to exposure of the underlying soft and hard tissue.
|Sutured||Left palate – creating flap, 6915 blade||Left palate – completing graft harvest|
Virtually all flap (osseous) surgery I have performed since I was 35 has been done in a mirror. There are situations where I crane my neck and hunch over to see (almost always this will be when suturing something), but in all honesty, each of us “pay” for this sort of habit sooner or later. Neck and back problems are among the most common motivations students attending the course Jean and I teach in Newport share with us. While loupes with a long focal length used with a mirror offer good ergonomics when performing palatal surgery, the operating microscope used with a mirror offers excellent ergonomics, superior visual clarity and shadow-free illumination even on the distolingual aspect of maxillary second molars.
Palatal flap/distal wedge procedure: my assistant is helping to retract the patient’s lower lip and the palatal flap with a suction tip as I work on the distal aspect of #2 using a mirror
Palatal flap/distal wedge procedure: assistant is observing me work and prepared to retract or suction as needed
There are some simple keys I have found to minimizing frustration and maximizing effciency when using the ‘scope for palatal flap procedures. It is critical that your assistant is willing and able to aid in flap retraction and to work outside their usual “box”.
Connective tissue graft harvest, left palate. The patient’s head is tilted back and to the left. Operator is close to the patient, arms close to sides, ‘scope tilted to allow direct vision
Suturing, right palate: note the ‘scope tilt, operator slightly to patient’s right. Patient is turned toward the operator and tilted back
I have found that suturing of posterior flap surgeries is one of the most challenging ‘scope procedures. Inevitably, if pressed for time, if the patient is less than ideally cooperative, if bleeding is an issue, I will, as I mentioned, revert to my loupes. However, especially for distal wedge areas and cases where regenerative materials have been placed which depend on precise closure, the microscope offers the best solution.
As a final thought, I would offer this suggestion, which I make to our students at NCoFI. Consider yourself a student of this discipline – mastery of the operating microscope – no matter what level of mastery you attain. Be patient with yourself and your staff. Don’t be in a rush. Break down the complex into manageable steps. And by all means, if you get frustrated, remember to breathe. If you get really frustrated, swing the ‘scope out of the way and put on your loupes. And come back and try it again tomorrow with a fresh approach.